During 2010, I had interned with an organisation called Society for Community Health Awareness Research and Action (SOCHARA), as part of the Community Health Learning Programme(CHLP). I was posted at the Community Health Cell (CHC), Chennai for a few months where I was guided by two health activists. I wanted to gain more insight about institutional deliveries in Tamil Nadu. So I interacted with some experts in the field of Community Health.
Rural Women’s Social Education Centre (RUWSEC)
As part of the internship, I attended a community focused group meeting at (RUWSEC). The NGOs, health workers and beneficiaries in the meeting wanted to define safe motherhood (technical, social) and bring about indicators of safe motherhood. The stakeholders discussed “safe motherhood” and the necessities required to achieve at homes, and then evaluated the quality of public health institutions and their services.
Mobility India and Tribal Health Initiative (THI)
In 2007, I had interned with Mobility India in Bangalore an NGO helping persons with disability and got insights on motherhood as part of it. I also visited an NGO called THI in 2009 at Sittilingi, near Dharmapuri, Tamil Nadu. The tribal inhabitants of the village — women as old as 17 were trained to manage deliveries, complications and assist in surgeries by the NGO members and the tribal hospital senior staff.
The hospital had a homely atmosphere with many traditional types of equipment and was built resembling the tribal houses of the village. I was also allowed to witness a delivery and it was a life-altering experience for me. The hospital was well equipped; the staffs were efficient and friendly. Some beneficiaries mentioned that it was not only safe to deliver a baby there was also an enriching and satisfying experience.
The rise of the Institutional Deliveries:
At first infant mortality was a huge issue till a document named ‘Where is the M in MCH?’ (Rosenfield, A.; Maine, D.), was published in 1985. The article questioned the very little importance given to mothers in maternal and child health (MCH) programs. After that, maternal mortality became an urgent issue to be attended worldwide. Many schemes were adopted by the Government of India. Under Janani Suraksha Yojana (JSY) scheme, comprehensive emergency services were formed and deliveries were pushed to Primary Health Centres (PHC). There was a slow rise in institutional deliveries from 25% to 80% from the 1970s onwards. But the supply of these services was lesser than the demand and the scheme became a failure. Nevertheless, in Tamil Nadu, the scenario was different where supplies were higher than the demand so it was an immediate success right from the 1980s.
Decline of Home Deliveries
At first, home deliveries were present in the villages. They were conducted by Dais/Traditional Birth Attendants (TBA). The Indian government, to stop maternal mortality started various interventions like training the midwives in the villages.
But the project was abandoned entirely deeming the training to be a failure.The training module for the Dais was not evaluated. There were no steps taken by the Government to check the flaws in the training. Instead, the Dais were blamed for their lack of knowledge for the failure of the training.
As of 2010, midwives no longer conducted or assisted in deliveries. They were debased and stripped of their jobs. But a few were retained in the PHCs as sanitary workers. They were allowed to do only menial jobs and earn around Rs.500 per month. They were not recognised by the government as authorised experts for conducting deliveries.
Government’s Attitude toward Home Births:
Home births were considered as unhygienic and barbarous by Government health staff and public health officials. According to them, safe motherhood could happen only at PHCs with technical provisions and schemes. People at homes did not know how to handle deliveries. There was no electricity; no space to have the equipment, or bring it to homes. Especially in poor people’s houses, mothers lay on the floor for delivery. Some mothers worked until the day before the delivery. In a case of emergency/ sudden labour, bringing these mothers to the PHC was difficult, as they were not easy to locate in interior villages.
But they stated that the scenario was different if the mother arrived at the PHC a day before the delivery. She could stay there for three days. While she was there she could be properly monitored. Complications could be easily referred to specialised hospitals. Audits and accountability of emergencies and deaths could be recorded, as centres were located at accessible areas for the health staff. All these services were impossible to be achieved on a door to door basis by sending the nurses and the public health staff to interior villages that housed pregnant women.
Doctors complained that the TBAs caused infant deaths. The mother and TBAs gave sugar water to newborn babies; gave oil-bath; and blew into their mouths & noses to remove dirt. The babies died of infections and pneumonia consequently. The mothers were illiterate and ignorant about neonatal care. They did not go to higher specialists when their babies were referred during complications, worried about expenditure and relied on faith-based treatments.
For safe motherhood, women need to take care of birth spacing, nutrition, ante-natal checkups and need to have iron / folic acid abundantly. Social workers should counsel mothers about negligence at home, breastfeeding, cleanliness, medication awareness, consanguineous marriage, and nutrition.
Government’s Programs to address MMR:
One of the reasons, the National rural health mission (NRHM) scheme was presented in India was to reduce Maternal Mortality Rate (MMR). The public health infrastructure before and after the introduction of NRHM is mentioned below:
*ANM – Auxillary Nurse Midwife
There was an acute lack of quality; and equipment did not function much at VHSCs so deliveries happened at block level PHCs only. Accessing public health was a major issue for mothers till 2005 .With the introduction of NRHM – 12 services were brought .They were: all PHCs working around the clock , establishment of basic emergency obstetric services , RTI and STI clinics , mobile medical units , indigenous ISM medicines, hiring of specialists , using good amount of funds for caesarean operations and family planning services, patient welfare societies , village health and sanitation committees, scan centers and audits , ‘108’ ambulance services.
He said that he had done many innovations in health services while being posted at Vellore and kanchipuram as a deputy director for public health. The government had evaluated those and instructed PHCs of other districts to follow the same .It had regularly sent a team of directors from other districts to observe these innovations to incorporate the same in other districts.
The early neonatal mortality rate was high (Safer Pregnancy in Tamil Nadu: From Vision to Reality; WHO Monograph) .A sensitive issue in a developing country, Dr. R mentioned that a project was being executed to approach the causes. The reasons have been located to be pneumonia, diarrhea, congenital problems, and asphyxia.
Government policies to reduce MMR
Dr. R explained about the Kalaigner’s Insurance scheme benefitting families whose annual income is less than Rs.72, 000 per year. It was not a scheme exclusively made to reduce MMR but nonetheless it’s a health scheme. People who were members of various welfare boards could avail that scheme. There were 22 welfare boards E.g.: welfare boards of construction workers. Also smart cards were given to these people that could be used by private and government hospitals. Through this scheme families could avail around 52 types of treatment.
The Janani Suraksha Yojana (JSY) scheme was brought for BPL families to reduce MMR all over India .It provided mothers with Rs.1400 for their nutrition, antenatal care, perinatal and post partum care .An improvisation of it was the Muthulakshmi Reddy Scheme (MRS) in Tamilnadu which provides Rs.6000 instead.
Some flaws of the JSY scheme was pointed out by health activists, beneficiaries and government officials alike. The scheme was not for mothers who
1, were below 19 years of age
2 have had more than two children
3 lived at husband’s house during pregnancy.
Some flaws mentioned about MRS were as follows:
Dr. SG pointed out that the scheme had been manipulated by various governments that held office through various time periods. Since then the amount has been raised from Rs. 450 to Rs.6000 consecutively, to target mothers for getting more votes and sustaining the parties.
She also said that the amount was of no actual benefit as the families used it for getting ambulances and other bribes.
Mr.AK pointed out that the mothers didn’t receive the money in installments before delivery but received the money only after they registered with the government. So no money was received for nutritional purposes during antenatal period, which defied the entire purpose of the scheme. He also pointed out that the nutrition scheme could be integrated with midday meals scheme (MMS) in villages by providing meals to mothers everyday instead of giving them the amount, but the government was reluctant to adopt such an idea.
Dr. RK agreed that the amount was not used for nutrition but for other multiple purposes. According to papers for MRS Rs. 1000 was to be distributed to mothers starting from the 7th month, but that was practically impossible due to accountability issues. So mothers got the amount at one installment after registration. He said that the scheme was beneficial for other aspects because getting a lump some amount of Rs. 6000 by BPL people by government was amazing. People also got Rs. 500 from JSY scheme though they had home deliveries. He said that the idea of integrating the nutrition scheme along with MMS, was articulated and government dismissed it. He said that government had administrative and financial issues, so it was not allowing funds properly for nutrition pilot projects but compensated for that gap by providing MRS.
Mrs. R said that the people who were not in the BPL category also gained money and planed for it .They didn’t use it for nutrition purposes. The money also went to some deserving hands, that were totally downtrodden and did not even earn a monthly income of Rs.6000.That, the schemes were an eye wash but could not be terminated totally and that it could destroy livelihoods if done .She said that integrating nutrition for mothers along with midday meals scheme consumed a lot of time, energy and money, something that government couldn’t afford. The quantity could be reached but the quality couldn’t be assured .For the food and screening for a month the 7th , 8th and 9thmonth mothers would have to come. For a day around 80 to 120 mothers turned up. To organize food for them was a tough job for PHC staff. Sometimes mothers, who still were due during 9th month, turned up and some mothers who were in the 6th month also turned up. It’s not feasible to provide them food everyday .She stated that if government considered this and allotted a separate department to execute this project, the goal could be achieved.
Maternal Morbidity- a persistent issue:
Dr.SG said that, though Tamil Nadu government had successfully reduced maternal mortality rates (MMR), the question of maternal morbidity had not been addressed anywhere, be it short term or long term.
For this, Dr. RK’s take was that, for maternal morbidity issues there was screening during 7th, 8th 9th month for mothers to anticipate complications and treat them. E.g.: heart diseases, hyper tension, eclampsia, gestational diabetes, infant morbidity and anemia.
But Dr. SG complained about maternal and infant morbidity after delivery. Mainly mothers after discharge were not followed up. E.g.: Anemia. She said that she had not seen public health institutions keeping track on post partum complications, statistics and also the quality of care received for it.
Some of the health workers quoted some incidences about system gaps especially in auditing deaths or morbidity. Maternal or infant morbidity during delivery or within the post-partum period had to go through government auditing. The families had to be taken by the health workers to the collector to report. In this procedure, the government hospital staff was negligent and provided less quality services once cases were referred to them .The government staff did not know how to tackle complications. They disrespected the health workers in the villages, saying they did not have enough knowledge. They became evasive and blamed the health workers if there was health system failure, to save themselves from higher authorities.
The cultural, gender and social discrimination in giving services:
Abortion, contraception pills or family planning concepts had all become cultural and religious issues. Dr. SG has reported that the mothers faced discrimination and had issues regarding privacy and abortion procedures. The abortion procedures were very tedious and harmful. Women contraceptives were not available widely in the market and if available were inaccessible by the general population due to unreasonable costs. Married mothers did not have a problem as government wanted to promote family planning. But unwed mothers were treated the worst, by government health staff. The government saw premarital sex and motherhood as a blasphemy.
She had also reported that government was selective about the messages it proliferated. Women controlled options were not considered especially in the cases of safe abortions. They only talked about condoms (male controlled) but not women controlled techniques to prevent pregnancy. No emergency contraceptive pills were available. And for family planning, the painful manual procedures were to be experienced by the mothers. She also prompted that there could be issues of social discrimination when it to came to accessibility of services that were not being discussed anywhere. E.g. People affected with HIV, SCs, and STs, though for family planning SCs and STs had cash incentives .For safe motherhood in general if there were any options, was a question.
When enquired about the gender bias to Dr. RK, he mentioned that the public health administration was trying to popularize male sterilization and nose scalpel vasectomy, a china procedure. The program was on and government was funding for it. The staff was trying to negotiate with government to increase Oral Contraceptive Pills (OCP). Dr. RK also countered that in Vellore 70% of PHC users were people belonging to schedule and most backward (Vannier) castes .So there wasn’t any special allotment for SC and STs and it was equal treatment for all people.
Reality gaps in theory and practice
A, Hygiene Issues:
Dr. S said, the most listed complaints were that the patients and the caretakers slept on the floor due to insufficient beds. There was also no hygiene as there was one sanitary worker for an entire building.
According to some of the beneficiaries and health workers from villages, the toilet facilities were unsupportive. Some NGOs provided toilet facilities with fees .The health facilities were late or unsafe sometimes, were not proportionate for the number of patients. There were less quality of deliveries and vaccines.
B, Inadequate Staff in government Hospitals:
According to Dr. S, the ideal staff ratio in a government hospital ought to be
1 severe complication baby = 1 nurse
8 babies needing medication = 1 nurse
40 babies = 6/7 pediatricians
One social worker.
But in reality she pointed out that there was just one sanitary worker for the entire building consisting of different departments. One pediatrician was catering to fifty babies and totally 3 nurses .There was no social worker. Staffs were really less in secondary and tertiary hospitals. No amount of petitions and complaints had brought out radical actions on the behalf of the government.
To tackle the problem, the government official said that the work load was shifted to PHCs so that at tertiary level the doctors could just take care of complications. And government was giving certificates for diabetology and anesthesia by training MBBS holders in PHCs. DR. RK mentioned that the government was benevolent enough to have done that much.
But Dr. S contradicted the above claim reasoning that government was building new government hospitals all over the state and spent money for them. Since government did not get profit from old government hospitals, it had abandoned them totally.
C, Government Officials’ negligence:
Mrs. Renuka complained that sometimes when referrals were given from the PHC, the staff of government hospitals did not receive that immediately and that she recently gave complaints to the joint directors of government hospitals to fix that up.
Dr. RK claimed that only a few government directors worked sincerely. Coordinating with other directors was tough for him, as there were only a few motivated directors. There was also always a clash between directors of different districts. He felt a strain from his higher officials too. He said that the government sometimes was benevolent, but otherwise it discarded many ideas that were suggested due to monetary inadequacy, system gaps and staff deprivation.
D, Immunization services had been moved to PHCs:
A health worker complained that for polio vaccines the Village Health Nurses (VHNs) were supposed come to village households for health advocacy, antenatal checkups and polio vaccination .But recently even the immunization was moved to PHCs. She said that the mothers found it real hard to travel to PHCs for just an injection.
Dr. RK quoted an incident that had triggered the government to move the services to PHCs. In 2008, in Thiruvallur district of Tamil Nadu there had been four infant deaths. Some VHNs went to village and had given immunizations for normal babies without testing them for other issues like pneumonia or chest congestions which had caused the deaths. So, immunization was moved to PHC where Medical officer (MO) checked for all that before administering vaccines.
People had protested a lot but their voices were unheard, since the government could not take further blames. At PHCs, MOs screened, tested and then administered the vaccines .Through NRHM; they sometimes sent mobile medical units (MMU), for inspections only if an MO was present.
E, Inefficiency of ANMs:
I had accompanied Mrs. R for an inspection to two upgraded block PHCs -one in Parandhur and the other one at Thuruppukuzhi of Kanchipuram districts. These were previously block PHCs which had been upgraded as 30 bedded ones. They were then conducting a food mela at Parandhur, for all the pregnant women, giving them nutritious lunch and screening them for complications -a pilot project innovation executed by Dr. R in all the PHCs of Kanchipuram district.
There were labor rooms in two upgraded 30 bedded PHCs. Mothers in all different stages of labor were put in the same room. The women who had been aborted were also put in the same room. And the delivery room was not actually a separate room. It was a small seclusion in the same room as the labor ward. There was another delivery cabin adjacent to the current one, which was not in use, which was badly maintained. It was not put to use unless the staff had two simultaneous deliveries. The staffs were not in their uniforms at that time and were warned by Mrs. R about it.
Dr. RK had an enquiry with an ANM in Vallam PHC, kanchipuram district during his interview with me. The ANM had read the partograph of two labor cases the earlier day. Both cases were in the stage of complication since 6 to 8 hours had passed and the labors had not progressed. Despite knowing that the mothers ought to be transferred to the government hospital as emergency, she had retained both cases at the PHC for 11 hours. She had failed to act even after reading the partograph and so was sacked by the deputy director.
Mrs. R said that unlike in private hospitals where there will be many to assist, the ANMs had to work on deliveries single handedly by leading and taking responsibility. The ANMs needed to know the signs whenever a case got complicated and ought to do referrals on time without delay. They also needed to screen the mothers earlier during 7th, 8th and 9th month. They ought to anticipate appropriately if a case should be normal or caesarean.
She complained that some ANMs were new and practically inefficient to handle deliveries on their own. Those coming from private institutions may be good in theory, but practically they were not well informed. The situation in PHCs was that ANMs were ill equipped to handle deliveries so, they were given training before being posted at various PHCs. The only eligibility was a certificate authorizing them as government health workers. They were over burdened with responsibilities and were paid Rs.7500 per month.
F, Follow-ups were not done:
There were also issues about follow-ups done by the public health institutions. Usually the mother stayed in these institutions for three days after which she was discharged and she had to come for regular follow-ups. But some beneficiaries complained that doctors were not present for antenatal check ups or consultancies. Mondays and Wednesdays were reserved for consultations in the out patient departments. But the doctors never carried out consultations on Wednesdays. Even for emergencies at 11:00 am, the clinics were closed. Bed patients were alone given consultations. Mothers in the out patient departments (OPD), for follow-ups didn’t get consultations. The pregnant mothers in OPDs were forced to buy beds in the PHCs.
G, Bribe, Violation of Patients’ rights and schemes like BCP.
Some health workers complained that there were monetary issues for medicines especially before and after delivery .The mothers were forced to buy stuff like covers, soaps, blades. Depending on the money given, the staff took care of patients. Government hospital doctors took bribe during private practice at clinics, especially when mothers went for antenatal check-ups. There was also an increase in the bribe rates by government hospitals.
Dr. S also said that earlier people paid Rs.1000 to Rs.1500 for a baby for ambulance and other services but recently they got it free of cost according to government rules. But the ambulances were also ill equipped. She said that one of the reasons for infant mortality was that ambulances were available but there was no equipment in the ambulance for emergency. For e.g.: Oxygen tubes were not there. By the time baby arrived to the hospital it died. The health workers said that Emergency transport, on papers was supposed to be free but people were charged for it.
The most prominent complaints from beneficiaries and village level health workers were that there was a lot of physical abuse and coercion at PHCs. There was no space for complaints. People’s basic dignity and rights were being hampered for mothers and also for VHNs alike. Many VHNs felt the pressure from higher authorities. The mothers didn’t have the rights to even choose their hospitals.
Dr.S said that, once her federation RUWSEC organized an awareness talk on the birth companionship programme (BCP), there was a huge response from the beneficiaries and they were outraged that nobody from the government had taken initiative to disseminate such an important scheme to them, since previously they all had faced a lot of abuse in government hospitals regarding caretaking. Then a copy of the government order (GO) was given to all the women. But a lot of them were still denied access to the mothers at government hospitals, the GOs were rejected.
Possible ways forward
About safe motherhood, there were focused group discussions with beneficiaries, health activists and health service providers of some districts around Chennai, organized by the NGO RUWSEC.
They brought out a lot gaps that are present in the current public health institutions in Tamil Nadu. And they have raised a lot of demands, to see some changes in the functioning of the system.
According to them:
Abuse of women had to cease. Public health systems had to be provided with clean toilets. Bribe and corruption had to be abolished. All services ought to be free, as they are stated on paper. Unsafe abortion had to be checked. Basic medical provisions ought to be given. For examples: generator, transport, ambulance, blood banks, disposable needles, (delivery) pregnancy table, incubator, operation theatre.
They wanted qualified, professional medical officers who were practised professionals accessible at any time. For example : Nurses , dais , gynecologists , surgeons , child specialists , pediatricians , consultants / counselors (pre /post delivery ) . Follow up ought to be there after deliveries for the post partum period.
Family support / social support systems had to be good. The family ought be sensitized about providing good nutrition and assisting the staff in medical procedures and birthing process and to give appropriate psychological support. And a caretaker had to be allowed to assist the mother during the birthing process.
The mothers ought to have the right to choose hospital/ doctors / clinics. One such instance was quoted by health activist Dr. SG about an incident while having a meeting on safe motherhood with some beneficiaries in a village. The women claimed that even the technical aspects of medical policies were to be discussed with beneficiaries and that safe motherhood was possible at homes, and even some complications could be treated.
E.g.: A beneficiary stated home deliveries could happen and that syringes could be stored in nearby shops that could control hemorrhage etc. close to homes rather than PHCs so that women could attend to complications at home instead of travelling to PHCs that were very far. And midwives could be trained in the administration of injections and better use of equipment and medication. And safe motherhood can be practiced at homes.
They said that safe motherhood could happen anywhere be it public health institutions or home. But in reality, they had to opt for institutions since the equipment couldn’t be had at homes. But they definitely wanted their right to choose whichever hospital they wanted to give birth. Safe motherhood happening at home was an ideal condition for them at that moment, which could eventually be put into practicality later.
The above gives some insight and is representative of evaluation of the quality of services received by the people from Tamil Nadu’s public health institutions (PHI). It also gives us a picture of how far is safe motherhood being practised in PHIs in TamilNadu. As of current date, it gives us scope to envisage if birthing processes can be brought to homes, by adding a few complementary services to make them effective instead of institutionalising them.